Updated 2025 test bank for the Adult Health 2 HESI Exam, featuring accurate and comprehensive questions with verified answers based on current nursing practices and HESI standards.

Updated 2025 test bank for the Adult Health
2 HESI Exam, featuring accurate and
comprehensive questions with verified
answers based on current nursing practices
and HESI standards.




A female patient's complex symptomatology over the past year has culminate
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d in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient'
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s following statements demonstrates the need for further teaching about the d
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isease?


A. "I'll try my best to stay out of the sun this summer."
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B. "I know that I probably have a high chance of getting arthritis."
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C. "I'm hoping that surgery will be an option for me in the future."
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D. "I understand that I'm going to be vulnerable to getting infections." -
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canswerc. SLE carries an increased risk of infection, sun damage, and arthritis
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. Surgery is not a key treatment modality for SLE.
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Midazolam (Versed) has been ordered for a patient to be administered by inje
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ction 30 minutes prior to a colonoscopy. The nurse informs the patient that on
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e of the most common side effects of this medication is which effect?
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,A. Decreased heart rate
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B. Amnesia c c




C. Constipation
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D. Dry mouth -
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answerb. Versed is known to cause amnesia and anxiolysis as well as sedati
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on and is therefore commonly used prior to certain procedures.
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The nurse is caring for a patient admitted with a spinal cord injury following a
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motor vehicle accident. The patient exhibits a complete loss of motor, sensory
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, and reflex activity below the injury level. The nurse recognizes this condition
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as which of the following?
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A. Central cord syndrome
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B. Spinal shock syndrome
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C. Anterior cord syndrome
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D. Brown-Séquard syndrome -
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answerb. About 50% of people with acute spinal cord injury experience a tem
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porary loss of reflexes, sensation, and motor activity that is known as spinal sh
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ock. Central cord syndrome is manifested by motor and sensory loss greater i
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n the upper extremities than the lower extremities. Anterior cord syndrome res
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ults in motor and sensory loss but not reflexes. Brown-
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Séquard syndrome is characterized by ipsilateral loss of motor function and c
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ontralateral loss of sensory function. c c c c




Which of the following clinical manifestations would the nurse interpret as repr
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esenting neurogenic shock in a patient with acute spinal cord injury?
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A. Bradycardia
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B. Hypertension
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,C. Neurogenic spasticity
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D. Bounding pedal pulses -
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answera. Neurogenic shock is due to the loss of vasomotor tone caused by inj
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ury and is characterized by hypotension and bradycardia. Loss of sympatheti
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c innervation causes peripheral vasodilation, venous pooling, and a decrease
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d cardiac output.
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The nurse is caring for a patient admitted 1 week ago with an acute spinal cord
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injury. Which of the following assessment findings would alert the nurse to the
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presence of autonomic dysreflexia?
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A. Tachycardia
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B. Hypotension
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C. Hot, dry skin
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D. Throbbing headache -
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answerd. Autonomic dysreflexia is related to reflex stimulation of the sympath
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etic nervous system reflected by hypertension, bradycardia, throbbing heada
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che, and diaphoresis.
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When planning care for a patient with a C5 spinal cord injury, which nursing di
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agnosis is the highest priority? c c c c




A. Risk for impairment of tissue integrity caused by paralysis
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B. Altered patterns of urinary elimination caused by quadriplegia
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C. Altered family and individual coping caused by the extent of trauma
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D. Ineffective airway clearance caused by high cervical spinal cord injury -
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canswerd. Maintaining a patent airway is the most important goal for a patient
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with a high cervical fracture. Although all of these are appropriate nursing diag
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noses for a patient with a spinal cord injury, respiratory needs are always the h
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ighest priority. Remember the ABCs.
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, The nurse is providing care for a patient who has been diagnosed with Guillain
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-
Barré syndrome. Which of the following assessments should the nurse prioriti
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ze?


A. Pain assessment
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B. Glasgow Coma Scale
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C. Respiratory assessment
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D. Musculoskeletal assessment -
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canswerc. Although all of the assessments are necessary in the care of patient
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s with Guillain-
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Barré syndrome, the acute risk of respiratory failure necessitates vigilant moni
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toring of the patient's respiratory status.
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Which of the following signs and symptoms in a patient with a T4 spinal cord in
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jury should alert the nurse to the possibility of autonomic dysreflexia?
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A. Headache and rising blood pressure
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B. Irregular respirations and shortness of breath
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C. Decreased level of consciousness or hallucinations
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D. Abdominal distention and absence of bowel sounds -
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answera. Among the manifestations of autonomic dysreflexia are hypertensi
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on (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manife
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stations, decreased level of consciousness, and gastrointestinal manifestatio
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ns are not characteristic.
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Which of the following interventions should the nurse perform in the acute car
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e of a patient with autonomic dysreflexia?
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